Examination of Witnesses (Questions 80 - 99)
THURSDAY 5 MARCH 1998
MR CHRIS
DAVIES and MR
MICHAEL HAKE
Audrey Wise
80. Mr Hake, you stated the increase in the home care hours.
Do you have a figure for the reduction over the same period of
the home help service?
(Mr Hake) We are probably dealing with the same service
but under a different name. The traditional model of home help
was that someone came in to do domestic tasks and provide other
practical help during the morning. Basically, it was a nine o'clock
to one o'clock service provided fairly thinly. There would have
been more people in that category. The health and personal social
services statistics show that fewer people receive help from home
care than home help in the past. But the service has focused on
the personal care needs of individuals to enable them to stay
at home, which is where most of them wish to be. But we are minority
players in this. The main providers of community care are carers.
We probably work with no more than 15 per cent of the elderly
population.
81. I think that tucked away in that response is the answer
that the home help service has gone because of the changes?
(Mr Hake) Yes.
82. Nursing tasks that were carried out by the health service—for
example, by district nurses—have moved into home care and
social services, and those who do not need such intensive personal
care but nevertheless need assistance to help them stay at home
drop off the end?
(Mr Davies) That is true in many areas of the country.
It is simply a matter of the prioritising of overall services.
Mr Hake is absolutely right. The total amount of home care that
local authorities deliver has gone up enormously but in the main
it is catering for people with high dependency needs. Perhaps
they need a call four or five times a day to deal with the basics
of getting out of bed, getting onto the toilet and getting clean
and fed. The old provision whereby someone would spend an hour
and a half a week to keep the windows clean and keep up people's
spirit, which is absolutely crucial, has largely been lost in
that prioritisation.
83. One is thinking perhaps of an elderly lady who cannot
manage very well. She may be hoovering and fall down the stairs.
It is one thing to present a picture of increased home care but
it is very incomplete unless it also covers what has been taken
away. You have said "not many areas". With the resources
available to your organisation, I would be very interested to
hear of just one area that still has a proper home help service.
I am desperately anxious to locate one. No witness who has come
before the Committee for some years has been able to quote one
area. Perhaps you would provide details of that in writing in
due course, if you can.
(Mr Davies) Yes.
Chairman
84. Mr Davies, your response was that this was related to
resourcing. Can you say how the £300 million input in October
of last year for winter pressures has impacted on this relationship
in view of your comment about resourcing?
(Mr Davies) The effect has been quite positive. All
the evidence is that local authorities and health authorities
have got together quite well and imaginatively to make sure, for
example, that assessment is available for people who occupy hospital
beds throughout the winter, including bank holidays and weekends,
so there is good throughput. There is evidence of the provision
of out-of-hours assessment for domiciliary care where people have
made sure that GPs can access that particular provision to keep
people out of hospital day or night.
85. Is that development a consequence of the injection of
that money?
(Mr Davies) Largely. Certainly, it was encouraged
by it. One of the ways of dealing with the problems between health
and local authorities is that if you tailor the funding systems
from central government in ways that encourage collaboration it
has an impact. I do not want to overclaim for the success of the
winter pressures money. It has been successful but it also been
a relatively comfortable winter as far as health and social services
are concerned. We should not blow our trumpet too loudly. But
it demonstrates that if money is channelled in a very firm way
so that people are told that they can have that help only if it
is spent collaboratively with social services on a jointly agreed
basis it addresses some of the difficulties.
Chairman: If your association is able to supply the Committee
with some evidence as to the way that has been used at local level
it will be very helpful.
Mr Lansley
86. Mr Davies, were you suggesting in your recent reply that
something would be gained year by year from top-slicing health
service resources to provide money on the basis of the presentation
of joint plans between health and social services for the spending
of money?
(Mr Davies) It is a difficult question because it
depends on whether one uses funding systems to encourage best
practice or allocates funding according to needs. There is a choice.
The problem is that if you say, "We will give you money only
if you behave in the way that we want", the areas that do
not behave well will lose out in terms of a needs-based allocation.
Health has tried to move towards allocating money to health authorities
on the basis of an assessment of the needs of populations. In
so far as you move to a reward-based system you shift away from
a needs-based allocation of money. That is my caution.
87. To what extent do you believe that the presentation of
joint plans for coping with winter pressures occurred because
the money was available and would not have been there otherwise
in the relationship between health and social services? In the
case of my own authority it presented a particularly good set
of plans, but essentially as far as that authority was concerned
it was producing plans that would have been presented in any case
to secure additional resources over and above what it expected
but not in order to create a relationship that would not otherwise
have existed. Is it a matter of putting on a good face in order
to get some money, or is the money genuinely creating a relationship
between these two bodies which would not occur without it?
(Mr Davies) Short-term money in particular will not
deal with deep-seated relationship problems of trust and understanding.
If you had a health authority and local authority that were unable
to work together that winter pressures money would not turn it
round over night.
88. I am trying to get a balance. Is it 50-50, 80-20 or what?
(Mr Davies) The evidence is that the winter pressures
money pretty well across the country has made a significant and
positive difference.
89. If you believe that to be the case the conclusion to
be drawn from it is that £300 million, as compared with the
£30 billion-odd that goes on the NHS and the £8 billion
on social services, caused health and social services to work
together whereas previously they had not done so satisfactorily,
yet you tell us that there are no Berlin Walls.
(Mr Hake) I believe that we must look at it in the
circumstances in which the money has arisen and the particular
issue that it is meant to address: winter pressures. Most of my
colleagues speak positively of their relationship with health
authorities. We have a long history of collaboration. The winter
pressures money must be seen in the context of established working
relationships surrounding the use of special transitional grant
which many authorities discuss with their health counterparts.
They agree where that spending will take place in the context
of their community care plans which provide a framework for community
services. But the bulk of NHS spending to which you refer goes
into acute care and about 40 per cent of local authority spending
is devoted to services for the elderly. In my experience, the
winter pressures money enabled us within those relationships to
develop things that we wanted to develop, for example intermediate
care which is substitutional in the sense that it stops people
from going into hospital and is rehabilitative in that it enables
people to take an intermediate step on leaving hospital. But it
has raised issues surrounding charging. As long as you make sure
that those services are within the NHS they are free. For example,
we agreed with our health authority a number of nursing home beds
funded by the NHS where people could go for rehabilitation to
release acute beds. Those funding mechanisms can be developed.
Perhaps it has shown us that we can do more in this context with
mainstream funding, but not all social services funding relates
to health functions. Some of it is for the care of children. One
of the questions in relation to pooling is what the director does
if he has to strike a balance within a cash limit and the pressures
are on the community care side rather than the children's side,
or vice versa. The same applies to the health service in relation
to acute care and community services. How does one get money into
a primary care-led NHS which enables the whole process to work
that much better?
90. In effect, you are saying that in future the winter pressures
money should not be given to the NHS for it to decide how social
services should spend it. You are saying that you were unable
to do the things that you wanted to do given the relationships
so that the money should be allocated according to need by social
services. The consequence of what you say is that if you incorporate
that money directly into the social services revenue support grant
settlement exactly the same outcome will arise. But I understood
Mr Davies to say that the winter pressures money caused something
to happen that would not otherwise have happened even if the same
money was available.
(Mr Davies) If what I said has led to that construction
it is unintended. I was saying that we had experience of the use
of joint resources. Joint finance is one. There is always a risk
with short-term funding. The complication that has always faced
social services departments is how to move away from the STG regime
for community care. It looks as if we will have to manage that
in 1999. We thought that we would have to do it this year and
were greatly relieved that we did not. One must use continuous
funding mechanisms to provide longer term solutions.
Mr Syms
91. My colleague has raised the subject of pooled budgets.
One of the points that witnesses have made to the Committee is
that pooled budgets may be a future solution. Are you nervous
about that approach? Do you think that it represents a loss of
sovereignty? Mr Davies began by saying that there were no clear
lines between health and social services and talked a great deal
about trust and confidence. If there were a pooled budget how
would each side know that it was getting value for money out of
it?
(Mr Davies) The virtue of pooled budgets is that they
help us to deal with the fact that it is impossible to draw the
lines between health and social care. By pooling one addresses
the whole issue and not just bits of it. I am in danger of going
on constantly about local trust and confidence between people.
I believe that it is absolutely vital. Pooling rarely works unless
you have a basis that enables you to work together. There are
good examples. In the case of my own authority, in the mental
health field we have agreed to identify and ring fence the spending
in health and social services on mental health. That money is
put into one budget that can be flexibly spent between the two
services. But neither local government nor health can say that
it will never change the amount of money that is put into that
budget. If needs change or the overall funding of either authority
changes they must be in a position to alter it. They cannot say
that they will cut every other service except the one that is
pooled. What one needs are timescales, notice periods and clear
agreements about the circumstances in which it would be done,
for example that it would never be done unilaterally and time
would be allowed to look at the implications of it as a whole
service. To say that resources will be pooled and that it will
be treated as one system of care and treatment has a lot going
for it.
92. Coming from a local authority background, one of the
difficulties one finds when one puts health and social services
together is that either one or the other cannot give a guarantee
of long-term funding. There is no point in coming together for
one year and having a pool and thinking that it is wonderful.
The local authority will always enter the caveat that it does
not know what the revenue support grant will be next year. Therefore,
you have one or the other trying to hook the other to ensure that
in year two, three and four reasonable programmes can be planned.
Is the method of funding a real problem?
(Mr Davies) You can do it if you are committed to
it. If you work out the systems you can make pooled budgets work,
but in a sense you are kicking against the pricks particularly
in terms of the one-year nature of local government funding. Local
authorities do not know with any degree of certainty until December
what they will be able to spend on their services on 1 April.
That is bound to be a restraint on the development of partnership
and commitment. It is a restraint but not a complete block. Pooling
can still be made to work if people want to make it work.
Mr Gunnell
93. When we met Department of Health officials last week
the impression I gained was that the whole exercise had not been
resource-driven. The impression that I got from your evidence
was that resources were of enormous importance. In part that is
based on what you said occurred in the `eighties when there was
a good deal of cost-shunting. That is the experience of social
services departments. You now say that since that emphasis has
shifted and it is continuing to shift you are less certain that
the money has shifted with it. Therefore, the impression that
I get from you is that the whole exercise is much more dependent
on resources compared with the impression that I received from
departmental officials last week. In the `eighties the Audit Commission
picked up the task of auditing health service matters. Has the
Audit Commission conducted any studies designed specifically to
look at whether or not funding has continued to shift and whether
there are particular financial burdens that are continually placed
on local authorities as a result of the system that we have? Have
you suggested to the Audit Commission that it investigates the
aspect of joint working form the point of view of the effectiveness
of funding? Have you made any proposals to the Audit Commission
since it has a similar responsibility on both sides of the fence?
(Mr Davies) I am not aware that we have. I believe
it is right to say—this may be a slightly risky statement—that
there are very few people in health or social care who contest
that the burden of cost has moved from the health service to social
services over the past 15 years. I do not think that that is disputed,
so in a sense we do not need the Audit Commission to make the
case. The vast majority of observers would accept that that has
happened. There are particular problems in health where it is
much more complicated to work out what is being spent on a particular
service. For example, there is so much elderly care in all kinds
of the health service. You cannot count only the elderly care
wards because if you walk into a general medical ward or general
surgical ward you will find that the vast majority of people there
are elderly. It is difficult to identify the total spending on
the health side and see how it shifts in relation to particular
client groups. It is much easier to do that in local government.
As a result of each of its studies the Audit Commission has said
that we will all achieve greater efficiency if we treat care as
a whole system and thus are prepared to move burdens of responsibility
around but have the wherewithal to move the money to reflect that.
94. But it has not suggested the possibility of pooled budgets?
(Mr Davies) I do not think the Audit Commission has
done that, but others like the Kings Fund and the Sainsbury Centre
have looked at the potential for pooled budgets in the area of
mental health and learning disabilities, which are perhaps the
two prime candidates for that sort of approach.
95. So, where initiatives have arisen they have arisen in
one sense from the health side rather than the local government
side of the divide?
(Mr Davies) I do not draw that conclusion. These things
work only if both sides are keen to make them work.
Julia Drown
96. You said that with good relationships and trust you could
make things work and, whether you had one organisation or two,
you would have to have the people working within it working well.
Is there not a fundamental difference in the objectives of the
two organisations—on the one hand, the health service and,
on the other hand, the local authorities—so that even if
there were significantly more resources there would always be
tension since the local authority would have so many calls on
that money, be it education, the fire service and the desire to
go back to the home help service to which Audrey Wise has referred?
Given the existence of that tension, it would lead to problems
for users of the service. One of my particular worries is that
the people who get stuck in the middle are at the most dependent
end of social services care provision. They are the ones who are
suffering from the tension and different objectives between the
two organisations.
(Mr Davies) I do not recognise a fundamental difference
in objectives. Certainly, that is not my experience. I believe
that generally it is easy to find common cause with health partners.
But the issue that you have touched upon is one that affects confidence,
in that the funding system is so different on the health and local
government sides. Health goes straight down the command structure
from the Secretary of State. On the local government side it comes
down from the Department for the Environment, Transport and the
Regions to local government and then social services. If I were
sitting on the health side I would be thinking, "If we enter
into a new partnership and put more money into it will the local
authority take it to build more roads?" The difference in
the financing structures creates problems along the way which
are insurmountable in that sense if one retains the value of local
democracy. If one says that locally elected councillors should
be able to reflect the priorities of their communities one must
have freedom to move money at local level. It seems to me that
it is not an "either/or" but a matter of finding the
balance between those two imperatives.
Chairman
97. Does your association have any evidence of different
relationships working positively or negatively at local level
where perhaps the structure of health provision differs? For example,
one may have community health provision in a separate trust from
acute provision. That occurs in my area. Where the margins are
between what social services do and what the health trust does
is something of a mystery. Based on the experience of your members,
is that a relevant factor or are there other organisational factors
at a local level that may have a bearing on relationships?
(Mr Davies) Probably, the most helpful organisational
feature is sharing the same boundaries.
98. Geographical boundaries?
(Mr Davies) Yes. If health authorities and health
trusts share the same boundaries with local social services authorities
co-operation is infinitely easier. One is planning for and committed
to the same population and one does not have to deal with a multiplicity
of relationships. In terms of the White Paper, as primary care
groups (with which we are very keen to work) develop there is
a danger that they will cut across every other sort of boundary
that presently exists. If that happens co-operation becomes geometrically
much more difficult.
99. I was more concerned with the existing arrangements where
you have a separate community health trust. Has that helped or
hindered the relationship where clearly you would be dealing with
two separate health organisations, an acute sector and a community
sector, presumably at the same time?
(Mr Hake) This is where social services skills in
networking come in. Community trusts are to be preferred to vertically
integrated arrangements where one has acute and community trusts
in one setting. It is then much more difficult to identify what
money is available for community services and develop a direct
relationship about the provision of services within the community.
There is another player on this field: GP fund-holders. They commission
some services directly from community trusts. My experience and
that of a number of authorities is that provision partnerships
can be developed with trusts. Perhaps the best example is joint
equipment stores. A considerable number of authorities have those
facilities whereby it does not matter whether a person is referred
by his doctor, hospital or social services. That is a jointly-funded
service. We tend to refer to it as "partnership funding"
rather than "pooling" because it means that we are bringing
our respective responsibilities and contributions together, identifying
what they are and what our funding contributions are and making
it work. In that way you can ensure that there is accountability
particularly for local authority money and pursue value for money.
Another area in which one can generate joint services is bathing,
particularly where there are fund-holders. We have developed joint
services that remove the barrier on the basis of partnership.
There is so much health money and social services money coming
in. That would be more difficult in a combined trust that was
merged with a hospital. That is an issue for the future as the
nature of acute sector activity changes. This is another change
that is occurring in addition to the re-definition of long-term
care boundaries. As one moves to new forms of intermediate care
there will be an issue of who provides it and how the relationships
develop. All of that will happen particularly in the context of
increasing numbers of older people. Some of the perceptions about
cost-shunting derive from demographic factors rather than responsibility.
There is more service going on in totality. A lot more money has
gone into the system, and the service is occurring in different
places as a result of medical advances which mean that certain
things can now be done in the community whereas before the client
would have gone into hospital. We must keep pace with those changes
and work in a way that makes sense to the end user.
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